Provider Demographics
NPI:1497128953
Name:FLEMING ISLAND PLASTIC SURGERY LLC
Entity Type:Organization
Organization Name:FLEMING ISLAND PLASTIC SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DELEGATED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:DELP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-874-7215
Mailing Address - Street 1:1679 EAGLE HARBOR PKWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-4815
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1679 EAGLE HARBOR PKWY
Practice Address - Street 2:SUITE C
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4815
Practice Address - Country:US
Practice Address - Phone:904-348-0727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME107749208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty